Working between systems: Professional identities and role scopes for greater integration of coordinator and navigator roles into care systems

Background: As the health and social needs of patients and families increase in complexity, a growing workforce is being employed to assist patients and families in navigating care at the interface between health and social care systems. These critical roles operate under a range of care models including patient navigation, social prescribing, case management, and care coordination,

(1). However, role scopes, role boundaries, tasks and responsibilities of this “in-between” workforce are often poorly understood by patients, health professionals, social care providers, managers and policy-makers,

(2). At least 20 different task domains and no less than 78 role titles have been used to describe these roles across diverse models of care, creating confusion and uncertainty about who these workers are, what services they provide and what training and support they need,

(1). Our case studies have shown that workers consistently find it challenging to maintain role boundaries, feel under-supported, often work in isolation and are in danger of burn-out.

Audience: The workshop will appeal to a diverse audience (e.g. clinicians, policymakers, care managers, patients, researchers) - anyone who works with care coordinators, navigators, or link workers in models of integrated care.

Approach: This 90-minute interactive workshop explores implementable strategies that could be adopted into organisational policy and processes for more seamless embedding of coordinator/navigator/link worker workforce by better defining role scopes, identifying essential training, exploring professional identities, continuing professional development and communities of practice.

The workshop will consist of the following:

1. (5mins) Introductions, workshop outline and purpose - Yvonne Zurynski (5 mins)

2.(15 mins) Expert rapid fire summary of latest research (A) International evidence on role scope, barriers, enablers, support needs - Yvonne Zurynski; (B) Embedding navigators into primary care in Australia - Nicholas Goodwin; (C) Policy, training and support for health and social care workforce in the UK - Annette Boaz.

3. (40 mins) Group discussion and interactive workshop using real-world scenarios and online tools such as Kahoot to explore: What critical evidence do we need to better support and integrate the link worker workforce? Which existing frameworks, policies or training programs could be leveraged? Would an international Delphi study help?
4. (30 mins) Report back, prioritisation of topic areas and next steps.

Outcomes: Anticipated learning and takeaways include a greater understanding of the challenges, enablers, frameworks and strategies for more seamless embedding of coordinator/navigator/link worker roles in care that integrates health and social care systems. There will be opportunities for interdisciplinary collaboration and the potential to support an international Delphi study to better define and streamline these crucial roles.

References: 1. Wijekulasuriya S, Wahlstrom L, Lewis S, Triandafilidis Z, Rojas C, Goodwin N, Semkina A, Boaz A, Norrie C and Zurynski Y. (2025) Working between systems: an umbrella review of care navigator roles and responsibilities. Front. Health Serv. 5:1632307. doi: 10.3389/frhs.2025.1632307

2. Zurynski Y, Smith C, Siette J, Easpaig BNG, Simons M, Knaggs GT. (2021) Identifying enablers and barriers to referral, uptake and completion of lifestyle modification programmes: a rapid literature review. BMJ Open. 11:e045094. doi: 10.1136/bmjopen-2020-045094